Laparoscopic versus open surgery for suspected appendicitis

A Case Report of Perforated Appendix Vermiform Attached to the Left Ovary

Acute appendicitis, a typical abdominal emergency, presents in nonperforated and perforated forms. While nonperforated cases often respond well to antibiotics or appendectomy, perforated cases pose more significant challenges. We report a unique case of appendicitis in a 34-year-old female with an unusual anatomical adherence to the left ovary. The patient successfully underwent laparoscopic surgery, during which precise incisions were made to accommodate the unique location of the appendix. This tailored approach contributed to a positive surgical outcome. This case underscores the importance of tailored surgical approaches in managing complex appendiceal variations.

Surgical Outcomes and Quality of Care Among Adult Appendicitis Patients: A Comparative Study of Tertiary Care Hospitals and Regional Hospitals

BACKGROUND

Acute appendicitis is one of the most common abdominal emergencies, with management approaches that vary depending on the available resources and setting. However, there is a lack of studies on the differences of surgical outcomes and quality of care between tertiary care hospitals and regional hospitals.

METHODS

This multicenter retrospective study included 2158 consecutive adult patients between January 2014 and June 2018 at three hospitals. The patient cohort was divided into regional hospital group (N = 1223) and tertiary care hospital group (N = 935). Baseline characteristics and perioperative outcomes were compared, and factors associated with surgical delay and postoperative complication were investigated.

RESULTS

Patients in tertiary care hospital group had longer surgical waiting time (17.3 vs. 12.0 h, p < 0.001), higher risks of surgical delay exceeding 24 h (OR = 2.94, 95% CI 2.17-4.01, p < 0.001), longer operation time (64 vs. 50 min, p < 0.001), more appendix perforation (22.4 vs. 13.3%, p < 0.001), and higher hospital cost compared with regional hospital group. In multivariate analysis, factors associated with surgical delay were tertiary care hospital (OR = 2.94, 95% CI 2.18-4.01, p < 0.001) and delay diagnosis (OR = 18.7, 95% CI 11.7-30.1, p < 0.001), while those associated with postoperative complications were older age (OR = 1.02, 95% CI 1.00-1.04, p = 0.013), male sex (OR = 2.38, 95% CI 1.11-5.52, p = 0.031), surgical delay (OR = 2.99, 95% CI 1.30-6.47, p = 0.007), and appendix perforation (OR = 5.61, 95% CI 2.72-11.85, p < 0.001).

CONCLUSIONS

Patients at tertiary care hospitals had longer waiting time, more surgical delays, and appendix perforations, and these were risk factors of postoperative complications. Establishing an effective referral system to redirect appendicitis patients with less complex medical histories from tertiary care hospitals to regional hospitals may enhance the quality of patient care and outcomes, while also reducing medical costs.

The role of intraoperative swab during appendectomy in patients with uncomplicated and complicated appendicitis

INTRODUCTION

Bacteria play an important role not only in pathogenesis of appendicitis but also in the postoperative course of patients. However, the usefulness of an intraoperative swab during appendectomy is controversial. The primary aim of this study was to investigate the impact of intraoperative swab during appendectomy on the postoperative outcome in patients with uncomplicated and complicated appendicitis.

METHODS

A retrospective analysis was conducted on a consecutive series of 1570 adult patients who underwent appendectomy for acute appendicitis at the University Hospital Erlangen between 2010 and 2020. Data regarding the intraoperative swab were collected and analyzed for the entire cohort as well as for patients with uncomplicated and complicated appendicitis.

RESULTS

An intraoperative swab was taken in 29% of the cohort. The bacterial isolation rate in the obtained intraoperative swabs was 51%, with a significantly higher rate observed in patients with complicated appendicitis compared to those with uncomplicated appendicitis (79% vs. 35%, p < 0.001). The presence of a positive swab was significantly associated with worse postoperative outcomes, including higher morbidity, increased need for re-surgery, and longer hospital stay, when compared to patients without a swab or with a negative swab. A positive swab was an independent risk factor for postoperative morbidity (OR 9.9 (95% CI 1.2-81.9), p = 0.034) and the need for adjustment of postoperative antibiotic therapy (OR 8.8 (95% CI 1.1-72.5), p = 0.043). However, a positive swab resulted in postoperative antibiotic therapy adjustment in only 8% of the patients with bacterial isolation in the swab.

CONCLUSION

The analysis of swab samples obtained during appendectomy for acute appendicitis can help identify patients at a higher risk of a worse postoperative outcome. However, the frequency of antibiotic regime changes based on the swab analysis is low.

Robotic Appendicectomy: A review of feasibility

Acute appendicitis is one of the most common abdominal emergencies. There has been an increasing use of robotic abdominal surgery. However, it remains underutilised in emergency settings. This study aimed to systematically review robotic appendicectomy (RA) feasibility. A 20-year systematic review was performed, along with quality assessment. The research protocol was registered with PROSPERO. The search yielded 1,242 citations, including 9 articles. The mean quality score was 10.72 ± 2.56. The endpoints across the studies were rate of conversion to open surgery, length of hospital stay, blood loss and operative time. RA is a safe, feasible technique that can be performed in elective and emergency settings with minimal blood loss. The operative time and hospital stay were within acceptable limits. Robotic surgery's major drawback is its high cost and limited availability. Future studies evaluating RA with a focus on its application during emergencies and its cost-effectiveness are recommended.

Open Versus Laparoscopic Appendectomy: A Post Hoc Analysis of the EAST Appendicitis MUSTANG Study

Background: We sought to understand which factors are associated with open appendectomy as final operative approach. We hypothesize that higher American Association for the Surgery of Trauma (AAST) Emergency General Surgery (EGS) grade is associated with open appendectomy. Patients and Methods: Post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated and Gangrenous (MUSTANG) prospective appendicitis database was performed. All adults (age >18) undergoing appendectomy were stratified by final operative approach: laparoscopic or open appendectomy (including conversion from laparoscopic). Univariable analysis was performed to compare group characteristics and outcomes, and multivariable logistic regression was performed to identify demographic, clinical, or radiologic factors associated with open appendectomy. Results: A total of 3,019 cases were analyzed. One hundred seventy-five (5.8%) patients underwent open appendectomy, including 127 converted from laparoscopic to open. The median age was 37 (25) years and 53% were male. Compared with the laparoscopic group, open appendectomy patients had more comorbidities, higher proportion of symptoms greater than 96 hours, and higher AAST EGS grade. Moreover, on intraoperative findings, the open appendectomy group had a higher incidence of perforated and gangrenous appendicitis with purulent contamination, abscess/phlegmon, and purulent abdominal/pelvic fluid. On multivariable analysis controlling for comorbidities, clinical and imaging AAST grade, duration of symptoms, and intra-operative findings, only AAST Clinical Grade 5 appendicitis was independently associated with open appendectomy (odds ratio [OR], 5.63; 95% confidence interval [CI], 1.24-25.55; p = 0.025). Conclusions: In the setting of appendicitis, generalized peritonitis (AAST Clinical Grade 5) is independently associated with greater odds of open appendectomy.

Bacterial pathogens in pediatric appendicitis: a comprehensive retrospective study

Background

Appendicitis is a frequent condition, with peak incidences in the second decade of life. Its pathogenesis is under debate, but bacterial infections are crucial, and antibiotic treatment remains essential. Rare bacteria are accused of causing complications, and various calculated antibiotics are propagated, yet there is no comprehensive microbiological analysis of pediatric appendicitis. Here we review different pre-analytic pathways, identify rare and common bacterial pathogens and their antibiotic resistances, correlate clinical courses, and evaluate standard calculated antibiotics in a large pediatric cohort.

Method

We reviewed 579 patient records and microbiological results of intraoperative swabs in standard Amies agar media or fluid samples after appendectomies for appendicitis between May 2011 and April 2019. Bacteria were cultured and identified via VITEK 2 or MALDI-TOF MS. Minimal inhibitory concentrations were reevaluated according to EUCAST 2022. Results were correlated to clinical courses.

Results

Of 579 analyzed patients, in 372 patients we got 1330 bacterial growths with resistograms. 1259 times, bacteria could be identified to species level. 102 different bacteria could be cultivated. 49% of catarrhal and 52% of phlegmonous appendices resulted in bacterial growth. In gangrenous appendicitis, only 38% remained sterile, while this number reduced to 4% after perforation. Many fluid samples remained sterile even when unsterile swabs had been taken simultaneously. 40 common enteral genera were responsible for 76.5% of bacterial identifications in 96.8% of patients. However, 69 rare bacteria were found in 187 patients without specifically elevated risk for complications.

Conclusion

Amies agar gel swabs performed superior to fluid samples and should be a standard in appendectomies. Even catarrhal appendices were only sterile in 51%, which is interesting in view of a possible viral cause. According to our resistograms, the best in vitro antibiotic was imipenem with 88.4% susceptible strains, followed by piperacillin-tazobactam, cefuroxime with metronidazole, and ampicillin-sulbactam to which only 21.6% of bacteria were susceptible. Bacterial growths and higher resistances correlate to an elevated risk of complications. Rare bacteria are found in many patients, but there is no specific consequence regarding antibiotic susceptibility, clinical course, or complications. Prospective, comprehensive studies are needed to further elicit pediatric appendicitis microbiology and antibiotic treatment.

Post-Operative Outcomes of Laparoscopic Appendectomy in Acute Complicated Appendicitis: A Single Center Study

BACKGROUND

Acute appendicitis (AA) is a surgical emergency because of inflammation in the appendix leading to swelling, whereas acute complicated appendicitis is characterized by a gangrenous or perforated appendix with or without periappendicular abscess, peritonitis, and an appendicular mass. The laparoscopic approach in complicated acute appendicitis is a viable alternative method but is not practiced in all cases because of technical difficulties and unpredictable complications. Thus, the present study aimed to evaluate the primary and secondary outcome predictors of laparoscopic appendectomy in complicated appendicitis.

METHODS

A single-center prospective observational study was carried out after the approval of the Institutional Ethics Committee (IEC). A total of 87 complicated acute appendicitis patients were included in the study. Clinico-demographic features such as age, gender, duration of surgery, post-operative pain, and hospital stay were monitored in different age groups of <20, 20-39, and >40 years, and the primary and secondary outcomes of laparoscopic surgery in acute complicated appendicitis were measured.

RESULT

Acute complicated appendicitis cases were observed mostly in people older than 42 years in the total study population. Laparoscopic appendectomy was conducted in all 87 acute complicated appendicitis patients, and the major surgical outcome predictors were monitored, such as mean operating time (87.9 minutes), post-operative pain (3.9 scores), and post-operative stay (6.7 days). Post-operative complications such as drain site infection (1.14%), enterocutaneous fistula (2%), and intra-abdominal abscess (7%) were observed.

CONCLUSION

Based on our observations, a laparoscopic appendectomy can be considered a viable alternative with an acceptable complication rate. Operative time varies from 84 to 94 minutes in different age groups and with the extent of the disease.

Current status of laparoscopic surgery usage in Türkiye: A middle-income country

Objectives

This study aimed to determine the usage status of laparoscopic procedures in general surgical practice in Türkiye, which is a sample of middle-income countries.

Material and Methods

The questionnaire was sent to general surgeons, gastrointestinal surgeons, and surgical oncologists who have completed their residency training and are actively working in university, public or private hospitals. Demographic data, laparoscopy training and the period of education, the rate of laparoscopy use, the type and volume of laparoscopic surgical procedures, their views on the advantages and disadvantages of laparoscopic surgery, and the reasons for preferring laparoscopy were determined with a 30-item questionnaire.

Results

Two hundred and forty-four questionnaires from 55 different cities of Türkiye were evaluated. The responders were mainly males, younger surgeons (F/M= 11.1/88.9 % and 30-39 y/o), and graduated from the university hospital residence program (56.6%). Laparoscopic training was frequently taken during residency (77.5%) in the younger age group, while the elderly participants mostly received additional training after specialization (91.7%). Laparoscopic surgery was mostly not available in public hospitals for advanced procedures (p <0.0001) but was available for cholecystectomy and appendectomy operations (p= NS). However, participants working in university hospitals mostly stated that the laparoscopic approach was the first choice for advanced procedures.

Conclusion

The results of this study showed that the surgeons working in MICs spent strong effort to use laparoscopy in daily practice, especially in university and high-volume hospitals. However, inappropriate education, cost of laparoscopic equipment, healthcare policies, and some cultural and social barriers might have negatively impacted the widespread use of laparoscopic surgery and its usage in daily practice in MICs such as Türkiye.

Outcome and quality of life in obese patients underwent laparoscopic vs. open appendectomy

Background

Although obesity is a popular reason for choosing laparoscopic appendectomy (LA) versus open appendectomy (OA), however, the question of whether there is a difference remains. Our goal is to investigate if there is a difference between OA and LA in obese patients.

Methods

Fifty-eight obese patients diagnosed with acute appendicitis according to ALVARDO score at department of surgery at Suez Canal university hospitals from March 2020 till August 2021 were included. The study participants were assigned in two groups LA and OA. This study aimed to comparing between LA and OA regarding intraoperative complications, length of hospital stays, post -operative pain, and rate of post-operative complications. Meanwhile, using SF-36 scoring questionnaire, the quality of life was compared between both groups.

Results

A total of 58 patients were included in the present study (LG = 29 patients and OG = 29 patients). The early post-operative complications (within 30 days after surgery) were significantly lower in the LA group (5 patients out of 29) than the OA (11 patients out of 29). Additionally, lower incidence of complications was noticed in the LA group (2 out of 29 patients) compared to OA (6 patients out of 29) beyond 30 days after operation. Patients with laparoscopic surgery had statistically significant higher overall quality of life scores (SF-36) (72 ± 32) compared to open surgery patients (66 ± 35) 2 weeks after operation.

Conclusion

The laparoscopic procedure was associated with lower incidence of post operative complications. However, open appendectomy was superior for a shorter operative time. Laparoscopic approach is not only used for therapeutic purposes, but also it has a diagnostic role.

Non-operative management of acute appendicitis in children

Appendicitis is one of the most common surgical emergencies in children and adults. Appendectomy as the standard care has been challenged in the recent years with growing evidence about non-operative treatment as a potential primary treatment in patients presenting with signs and symptoms suggestive of acute appendicitis. This review aims to establish where the recent research stands regarding conservative treatment of acute appendicitis, especially in children. There are several studies that report the potential safety and efficacy of treating acute appendicitis non-operatively. Several studies have challenged the concept of acute appendicitis being a progressive disease that always ends in perforation, rather than a disease that can present as different forms with only a defined number of cases progressing to perforation. The lack of randomized controlled studies is a limitation and well-designed randomized controlled trials are needed to determine the role of non-operative management of acute appendicitis in children.

Energy Devices for Clipless-Sutureless Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis on Utility and Safety

Background and Objectives: While laparoscopic appendectomy is standardized, techniques for appendiceal stump closure and mesoappendix division remain variable. Novel vessel sealing techniques are increasingly utilized ubiquitously. We sought to systematically summarize all relevant data and to define the current evidence on the safety and utility of energy devices for clipless−sutureless laparoscopic appendectomy in this systematic review and meta-analysis. Materials and Methods: This review was conducted following the PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science were systematically searched. Inclusion criteria included studies with laparoscopic appendectomy for appendicitis. The intervention included patients undergoing division of mesoappendix and/or securing of the appendicular base using diathermy (Monopolar or Bipolar or LigaSure Sealing Device) or Harmonic Scalpel (Group A) compared to patients undergoing division of mesoappendix and/or securing of the appendicular base using endoclip or Hem-o-lok or ligature (Group B). The methodological quality of the included studies was assessed using the Downs and Black scale. The outcomes of surgical site infection (SSI) or intra-abdominal collection, postoperative ileus, average operative duration, and length of hospital stay (LHS) were compared. Results: Six comparative studies were included; three were retrospective, two were prospective, and one was ambispective. Meta-analysis revealed a shorter operative duration in Group A with respect to appendicular base ligation (MD −12.34, 95% CI −16.57 to −8.11, p < 0.00001) and mesoappendix division (MD −8.06, 95% CI −14.03 to −2.09, p = 0.008). The pooled risk ratios showed no difference in SSI between groups. Additionally, no difference was observed in LHS. The risk of postoperative ileus was higher in group B regarding mesoappendix division (RR 0.56, 95% CI 0.34 to 0.93, p = 0.02), but no difference was found concerning appendicular base ligation. The included studies showed a moderate-to-high risk of bias. Conclusions: Clipless−sutureless laparoscopic appendectomy is safe and fast. Postoperative ileus seems less common with energy devices for mesoappendix division. However, the studies included have a moderate-to-high risk of bias. Further studies addressing the individual devices with surgeons of similar levels are needed.

Meta-analysis of the clinical efficacy of laparoscopic appendectomy in the treatment of acute appendicitis

Background

This paper compares the postoperative recovery of patients with acute appendicitis (AA) after laparoscopic appendectomy (LA) and open appendectomy (OA), aiming to determine the optimal diagnosis and treatment plan for appendectomy.

Methods

Related literature was retrieved from PubMed, Web of Science, Embase, CNKI and Wanfang databases. Articles on LA and OA for AA published between 2010 and 2021 were selected to extract data. Besides, Stata16.0 was used for meta-analysis.

Results

A total of 777 articles were retrieved, and 16 of them were finally selected. Totally, 1251 patients underwent LA, while 898 patients received OA. According to the results of meta-analysis, LA was associated with lower incidence of adverse reactions [OR = 0.257, 95% CI (0.162, 0.408), P < 0.001], shorter operation time (SMD = − 1.802, 95% CI − 2.435, − 1.169; P < 0.001) and hospitalization (SMD = − 1.184, 95% CI − 1.512, − 0.856; P < 0.001). In addition, compared with the OA group, LA was found with less intraoperative blood loss (SMD = − 3.650, 95% CI − 5.088, − 2.212; P < 0.001) and shorter recovery time of gastrointestinal function (SMD = − 3.010, 95% CI − 3.816, − 2.203; P < 0.001). Aside from all these, the counts of leukocyte (SMD = − 0.432, 95% CI: − 0.775, − 0.089; P = 0.013), neutrophil (SMD = − 1.346, 95% CI − 2.560, − 0.133; P = 0.030), and C-reactive protein (SMD = − 2.391, 95% CI − 3.901, − 0.882; P = 0.002) all decreased in a significant manner after LA.

Conclusion

Compared with OA, LA boasts the advantages of less adverse reactions, shorter operation time and hospitalization, fewer complications, and lower inflammatory response, evidencing its safety and feasibility of applying in the treatment of AA.

Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis

BACKGROUND

Laparoscopic appendectomy (LA) is the preferred approach in uncomplicated appendicitis. However, in patients with complicated appendicitis (CA), the best approach is still unclear though laparoscopy is being increasingly preferred over open appendicectomy (OA) nowadays.

AIM

To comprehensively review the current literature and compare the associations of LA and OA concerning various postoperative outcomes in order to determine the best approach for children with CA.

METHODS

The PRISMA guidelines were adhered to and an electronic database search was extensively performed. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Methodological and statistical heterogeneity, as well as publication bias of the included studies, were assessed.

RESULTS

Four randomized controlled trials (266 LA versus 354 OA) and thirty-six case-controlled trials (2580 LA versus 3043 OA) were included in the analysis. Compared to OA, LA has a shorter length of stay, a lower rate of surgical site infection as well as a significantly lower overall complication rate. The rates of intraabdominal abscess formation, post-operative fever, pneumonia and ileus are similar in the two groups. So are the rates of readmissions and reoperations. LA was also shown to have a shorter time taken to oral intake and a lesser requirement of analgesics as well as intravenous antibiotics. Operative time for OA was found to be significantly shorter than that for LA.

CONCLUSION

This meta-analysis objectively demonstrates that laparoscopy has a better overall complication profile compared to OA and should be the procedure of choice in children with complicated appendicitis.

Machine learning prediction model for postoperative outcome after perforated appendicitis

Purpose

Appendectomy for acute appendicitis is one of the most common operative procedures worldwide in both children and adults. In particular, complicated (perforated) cases show high variability in individual outcomes. Here, we developed and validated a machine learning prediction model for postoperative outcome of perforated appendicitis.

Methods

Retrospective analyses of patients with clinically and histologically verified perforated appendicitis over 10 years were performed. Demographic and surgical baseline characteristics were used as competing predictors of single-patient outcomes along multiple dimensions via a random forest classifier with stratified subsampling. To assess whether complications could be predicted in new, individual cases, the ensuing models were evaluated using a replicated 10-fold cross-validation.

Results

A total of 163 patients were included in the study. Sixty-four patients underwent laparoscopic surgery, whereas ninety-nine patients got a primary open procedure. Interval from admission to appendectomy was 9 ± 12 h and duration of the surgery was 74 ± 38 min. Forty-three patients needed intensive care treatment. Overall mortality was 0.6 % and morbidity rate was 15%. Severe complications as assessed by Clavien-Dindo > 3 were predictable in new cases with an accuracy of 68%. Need for ICU stay (> 24 h) could be predicted with an accuracy of 88%, whereas prolonged hospitalization (greater than 7–15 days) was predicted by the model with an accuracy of 76%.

Conclusion

We demonstrate that complications following surgery, and in particular, health care system-related outcomes like intensive care treatment and extended hospitalization, may be well predicted at the individual level from demographic and surgical baseline characteristics through machine learning approaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02456-1.

Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis

BACKGROUND

Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children.

OBJECTIVES

The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective.

SELECTION CRITERIA

We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies.

DATA COLLECTION AND ANALYSIS

We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity.

MAIN RESULTS

We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains.

AUTHORS' CONCLUSIONS

MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.

Evidence-based surgery for laparoscopic appendectomy: A stepwise systematic review

Introduction

Appendectomy is a common emergency surgery performed globally. Despite the frequency of laparoscopic appendectomy, consensus does not exist on the best way to perform each procedural step. We identified literature on key intraoperative steps to inform best technical practice during laparoscopic appendectomy.

Methods

Research questions were framed using the population, indication, comparison, outcome (PICO) format for 6 key operative steps of laparoscopic appendectomy: abdominal entry, placement of laparoscopic ports, division of mesoappendix, division of appendix, removal of appendix, and fascial closure. These questions were used to build literature queries in PubMed, EMBASE, and the Cochrane Library databases. Evidence quality and certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) definitions.

Results

Recommendations were rendered for 6 PICO questions based on 28 full length articles. Low quality evidence favors direct trocar insertion for abdominal entry and establishment of pneumoperitoneum. Single port appendectomy results in improved cosmesis with unclear clinical implications. There was insufficient data to determine the optimal method of appendiceal stump closure, but use of a specimen extraction bag reduces rates of superficial surgical site infection and intra-abdominal abscess. Port sites made with radially dilating trocars are less likely to necessitate closure and are less likely to result in port site hernia. When port sites are closed, a closure device should be used.

Conclusion

Key operative steps of laparoscopic appendectomy have sufficient data to encourage standardized practice.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Comparison of intra-abdominal abscess formation after laparoscopic and open appendectomy for complicated and uncomplicated appendicitis: a retrospective study

INTRODUCTION

Acute appendicitis (AA) is one of the most common causes of acute abdominal pain seen in emergency departments and appendectomy has been the preferred treatment of this disease for decades. Postoperative intra-abdominal abscess (PIAA) complicates 3% to 25% of appendectomies and the risk is highest following complicated appendicitis. However, the risk for intra-abdominal abscess formation after appendectomy is still a matter of debate.

AIM

To evaluate PIAA formation after open appendectomy (OA) and laparoscopic appendectomy (LA), in particular in complicated appendicitis.

MATERIAL AND METHODS

From January 2003 to December 2018, records of patients who underwent appendectomy with diagnosis of appendicitis were retrieved from a computer database for analysis.

RESULTS

During the study period, 1809 appendectomies were performed in our institution (939 LAs and 850 OAs). Twenty conversion cases were recorded. There was no difference between the incidences of PIAA (LA, 3.73% (35/939) and OA, 3.41% (29/850); p > 0.05). The incidence of PIAA in those with complicated appendicitis was: LA, 11/212 (5.19%) vs. OA 14/198 (7.07%); p > 0.05.

CONCLUSIONS

This retrospective study shows that the technique of appendectomy does not appear to affect the incidence of IAAs either in uncomplicated or in complicated appendicitis. However, laparoscopic appendectomy has the advantages of laparoscopic procedures, such as lower hospital stay and earlier return to activities, and should therefore be preferred for acute appendicitis.

Same-day discharge vs. observation after laparoscopic pediatric appendectomy: a prospective cohort study

Background

Through 2015, the practice at our university based free-standing children's hospital was to admit uncomplicated appendicitis patients for overnight observation post-operatively. Given the increasing body of evidence suggesting the safety and feasibility of same-day discharge after appendectomy for uncomplicated appendicitis, we elected to perform a prospective study evaluating the complication rates of same-day discharge compared to overnight observation at our institution, given our large volume of appendicitis.

Methods

Pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were analyzed. Data regarding demographics, admission, and discharge times and outcomes of complications, as well as readmissions, return to the emergency department, and nonscheduled clinic visits were collected and analyzing using chi-square and multivariate regression. Cost of stay data was obtained and analyzed using Mann-Whitney U test to compare non-parametric variables.

Results

Eight hundred and forty-nine laparoscopic appendectomies were performed for uncomplicated appendicitis during the study period, of which 382 resulted in same-day discharge and 467 in an admission for observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs. observation (2 vs. 6 patients; P=0.21) or in emergency department visits within 30 days (22 vs. 27 patients; P=0.98). There was no difference in the number of surgical site infections or extra clinic visits. There was a significantly lower median cost of stay for patients discharged home the same day at 29,150 dollars (25,644, 32,276, IQR) compared to a median of 34,827 dollars (31,154, 39,457, IQR) (P<0.0001).

Conclusions

Same-day discharge for laparoscopic uncomplicated appendectomy should be the new standard of care. This study found no differences in outcomes between the timing of discharge, with a significantly lower cost of stay for patients discharged home the same day.

Optical Fiber Array Sensor for Force Estimation and Localization in TAVI Procedure: Design, Modeling, Analysis and Validation

Transcatheter aortic valve implantation has shown superior clinical outcomes compared to open aortic valve replacement surgery. The loss of the natural sense of touch, inherited from its minimally invasive nature, could lead to misplacement of the valve in the aortic annulus. In this study, a cylindrical optical fiber sensor is proposed to be integrated with valve delivery catheters. The proposed sensor works based on intensity modulation principle and is capable of measuring and localizing lateral force. The proposed sensor was constituted of an array of optical fibers embedded on a rigid substrate and covered by a flexible shell. The optical fibers were modeled as Euler–Bernoulli beams with both-end fixed boundary conditions. To study the sensing principle, a parametric finite element model of the sensor with lateral point loads was developed and the deflection of the optical fibers, as the determinant of light intensity modulation was analyzed. Moreover, the sensor was fabricated, and a set of experiments were performed to study the performance of the sensor in lateral force measurement and localization. The results showed that the transmitted light intensity decreased up to 24% for an external force of 1 N. Additionally, the results showed the same trend between the simulation predictions and experimental results. The proposed sensor was sensitive to the magnitude and position of the external force which shows its capability for lateral force measurement and localization.

Fuentes de energía en apendicectomía laparoscópica en un programa académico de Cirugía general en Colombia

Introducción. La apendicectomía por laparoscopia se considera el patrón de oro en el tratamiento de la apendicitis aguda. Sin embargo, su disponibilidad es limitada en nuestro sistema de salud, principalmente por los costos asociados. El objetivo de este estudio fue evaluar la relación entre el uso de los diferentes tipos de energía y los métodos de ligadura de la base apendicular, con las complicaciones postoperatorias, al igual que describir los costos asociados. Métodos. Estudio observacional analítico de una cohorte retrospectiva de pacientes mayores de 15 años a quienes se les realizó apendicectomía por laparoscopia, en un hospital universitario entre los años 2014 y 2018. Se utilizaron modelos de regresión logística y lineal para evaluar la relación entre métodos de ligadura del meso y base apendicular, desenlaces operatorios y costos. Resultados. Se realizaron 2074 apendicectomías por laparoscopia, 58,2 % (n=1207) en mujeres, la edad mediana fue de 32 años. En el 71,5 % (n=1483) la apendicitis aguda no fue complicada. La energía monopolar para la ligadura del meso apendicular fue la utilizada más frecuentemente en 57,2 % (n=1187) y el Hem-o-lok® el más utilizado para la ligadura de la base apendicular en el 84,8 % (n=1759) de los pacientes. No se observaron diferencias estadísticamente significativas en la tasa de infección del sitio operatorio, reintervención o íleo. El uso de energía simple redujo los costos del procedimiento de manera significativa durante el período evaluado. Discusión. El uso de energía monopolar demostró ser una técnica segura, reproducible y de menor costo en comparación con el uso de energía bipolar, independientemente de la fase de la apendicitis aguda. Lo anterior ha permitido que se realicen más apendicectomías por laparoscopia y que los médicos residentes de cirugía general puedan realizar procedimientos laparoscópicos de forma más temprana.

The uncharted severity of complications after appendectomy for acute appendicitis in children: results from 348 consecutive patients

Appendectomy is the most frequently performed emergent procedure in paediatric patients. However, there is a wide heterogeneity in outcome definitions and, conversely, a lack of information about complications' severity. This study aims to analyse the outcome of children operated for acute appendicitis, with reference to complications' severity grading. This is a retrospective analysis of a prospectively collected database including all children who underwent emergent appendectomy between September 2013 and March 2020. Postoperative complications were defined according to standardized definitions and graded following Clavien-Dindo classification (CDC). The outcome was analysed in terms of postoperative morbidity, severity of complications, hospital readmission and length of hospital stay (LOS). 348 patients were analysed. Postoperative complications occurred in 18 (5.2%) patients; superficial and organ/space surgical site infections represented the most frequent complications (1.7% and 2.9%, respectively). Major complications (CDC ≥ IIIa) were seen in 4 (1.1%) patients. Median postoperative LOS was 4 (iqr 3-5) days, while hospital readmission was 1.1%. Postoperative complications, preoperative C-reactive protein values and presence of drainage were significantly associated with longer LOS at multivariate analysis. No difference in incidence and severity of complications was found in relation to children's adolescent age. Major complications among paediatric patients undergoing appendectomy for acute appendicitis in a general surgery department are rare. The application of standardized definitions and severity-based grading of complications is crucial for outcome analysis: our results are a useful reference for comparison between forthcoming studies.

A randomized clinical trial of technical modifications of appendix stump closure during laparoscopic appendectomy for uncomplicated acute appendicitis

Background

Closure of the appendix stump presents the most critical part of laparoscopic appendectomy. The aim of the present study was to compare the medical outcomes and cost analysis of laparoscopic appendectomy with respect to the different methods of stump closure.

Methods

This was a prospective randomized clinical trial conducted in a single institution (University Hospital Ostrava) within a 2-year study period. All included patients were randomized into one of three trial arms (endoloop, hem-o-lok clips or endostapler).

Results

In total, 180 patients (60 patients in each arm) were enrolled into the study. The mean length of hospital stay (3.6 ± 1.7 days) was comparable in all study arms. The shortest operative time was noted in the hem-o-lok subgroup of patients (37.9 ± 12.5 min). Superficial surgical site infection was detected in 4.4% of study patients; deep surgical site infection was noted in 1.7% of the patients. The frequency of surgical site infections was comparable in all study arms (p = 0.7173). The mean direct costs of laparoscopic appendectomy were significantly the lowest in the hem-o-lok subgroup of patients. Laparoscopic appendectomy is not a profit-making procedure in our institution (mean profit of made from the study patients was—104.3 ± 579.2 Euro). Closure of the appendix stump by means of endostapler presents the most expensive and the highest loss-incurring technique (p = 0.0072).

Conclusions

The present study indicates that all technical modifications of appendix stump closure are comparable with regards to postoperative complications. The stapler technique is significantly the most expensive. We concluded that hem-o-lok clips have the potential for becoming the preferred method of securing the appendix base during laparoscopic appendectomy. Trial registration NCT03750032 (http://www.clinicaltrials.gov).

Single site versus conventional laparoscopic appendectomy: some pain for no gain?

INTRODUCTION

The optimal laparoscopic appendectomy approach is not clear, comparing single site laparoscopic appendectomy (SILA) to conventional 3-port appendectomy (CLA). We investigated outcomes in pediatric patients comparing SILA to CLA: length of operation, length of stay, time to resumption of regular diet, follow up, rehospitalization, and cost.

METHODS

Data was collected from children 1 to 18 years with appendectomy at Loma Linda University from 2018 to 2020, operated by two surgeons. Analysis utilized two-sample T, chi-squared, and Fisher's exact tests.

RESULTS

Of 173 patients, 77 underwent SILA and 96 had CLA. There was no gender, age, or race difference between groups. Mean WBC was 17.5 × 10³/mL in SILA group, compared to 15.3 × 10³/mL in CLA group (P = 0.004). Operative time was 47.0 SILA compared to 49.5 minutes CLA (P = 0.269). Of SILA cases, 55.8% were simple appendicitis, while 53.3% of the CLA cases were simple (P = 0.857). Regular diet was resumed after 1.7 days in the SILA group, 1.1 days in CLA (P = 0.018). Length of stay was 2.9 days for SILA, 2.4 days for CLA (P = 0.144). Seven children required hospital readmission, 5 SILA and 2 CLA (P = 0.244). Five of the children who returned had intra-abdominal abscesses, of whom 4 had SILA. There was no difference in cost.

CONCLUSIONS

The operative techniques had similar outcomes and operative times. There was a trend toward more intra-abdominal abscesses in the SILA group. Further study and longer follow up is needed to determine if there is an advantage to one laparoscopic approach over another.

Laparoscopic Versus Open Appendectomy for Acute Appendicitis in Children: a Nationwide Retrospective Study on Postoperative Outcomes

PURPOSE

Our aim was to compare postoperative outcomes of laparoscopic and open appendectomies for acute appendicitis in children under the circumstance of widespread use of laparoscopic surgery.

METHOD

This study included data on laparoscopic and open appendectomies in children with acute appendicitis from the National Clinical Database, which is a Japanese nationwide surgical database, in 2015. The occurrence rates of complications within 30 days after the surgery and postoperative hospital stay were compared by univariate and multivariate analyses. p < 0.05 was considered statistically significant.

RESULTS

This study included 4489 appendectomies, of which 3166 surgeries (70.5%) were performed laparoscopically. Appendectomy was performed for complicated and uncomplicated appendicitis in 1765 (39.3%) and 2724 cases (60.7%), respectively. Postoperative complications within 30 days were observed in 246 operations (5.5%). Organ-space surgical site infection (SSI), deep wound SSIs, and superficial wound SSIs were observed in 2.3%, 1.0%, and 2.4% of operations, respectively. On multivariate analysis, the incidence of postoperative complications (odds ratio 1.21, 95% CI 0.90-1.64, p = 0.207) and the length of hospital stay (median 4 days in both groups, p = 0.835) were not significantly different between patients who underwent laparoscopic or open appendectomy. Subgroup analysis in complicated and uncomplicated appendicitis cases also demonstrated no significant differences in the incidence of postoperative complications between those who underwent laparoscopic or open appendectomy.

CONCLUSION

This study suggested that the occurrence of postoperative complication and the length of hospital stay in pediatric patients who underwent laparoscopic appendectomy are similar with those in pediatric patients who underwent open appendectomy for acute appendicitis.

Laparoscopic vs open surgery during the COVID-19 pandemic: what are the risks?

INTRODUCTION

The initial intercollegiate surgical guidance from the UK during the COVID-19 pandemic resulted in significant changes to practice. Avoidance of laparoscopy was recommended, to reduce aerosol generation and risk of virus transmission. Evidence on the safety profile of laparoscopy during the pandemic is lacking. This study compares patient outcomes and risk to staff from laparoscopic and open gastrointestinal operations during the COVID-19 pandemic.

METHODS

Single-centre retrospective study of gastrointestinal operations performed during the peak of the COVID-19 pandemic. Demographic, comorbidity, perioperative and survival data were collected from electronic medical records and supplemented with patient symptoms reported at telephone follow up. Outcomes assessed were: patient mortality, illness among staff, patient COVID-19 rates, length of hospital stay and postdischarge symptomatology.

RESULTS

A total of 73 patients with median age of 56 years were included; 55 (75%) and 18 (25%) underwent laparoscopic and open surgery, respectively. All-cause mortality was 5% (4/73), was related to COVID-19 in all cases, with no mortality after laparoscopic surgery. A total of 14 staff members developed COVID-19 symptoms within 2 weeks, with no significant difference between laparoscopic and open surgery (10 vs 4; p=0.331). Median length of stay was shorter in the laparoscopic versus the open group (4.5 vs 9.9 days; p=0.011), and postdischarge symptomatology across 15 symptoms was similar between groups (p=0.135-0.814).

CONCLUSIONS

With appropriate protective measures, laparoscopic surgery is safe for patients and staff during the COVID-19 pandemic. The laparoscopic approach maintains an advantage of shorter length of hospital stay compared with open surgery.

Risk of emergency surgery for complicated appendicitis: Japanese nationwide study

AIM

Appendicitis is divided into two categories: complicated appendicitis (CA) and uncomplicated appendicitis (UA). In pediatric patients with CA, the use of interval appendectomy (IA), which is non-operative management followed by elective surgery, has decreased the number of postoperative complications. Before discussing the merit of IA for adult patients, we need to clarify whether the frequency and seriousness of the complication rate after emergency surgery is higher for CA than for UA.

METHODS

This retrospective cohort study included adult patients who underwent appendectomy and who were registered in the National Clinical Database (NCD) from 2014 to 2016. Patients with CA who underwent emergency appendectomy comprised the CA group. Patients with UA comprised the UA group. Patients with chronic or recurrent appendicitis who underwent elective appendectomy comprised the elective appendectomy (EA) group. Primary outcomes were all morbidity, serious morbidity, and mortality within 30 days after appendectomy.

RESULTS

We included 109 256 patients in the study: 14 798 CA, 86 876 UA, and 7582 EA patients. Compared with the UA group, the rates of all morbidity, serious morbidity, and mortality were significantly higher in the CA group. All morbidity, serious morbidity, and mortality rates were significantly lower in the EA group than in the other two groups.

CONCLUSIONS

We confirmed that emergency surgery for CA places the patient at relatively higher risk. We also showed that the risk associated with EA is significantly lower than that for the other methods.

Appendicitis-Like Picture Induced by Foreign Body in a 2-Year-Old Boy

Background and Aim. Appendicitis is unusual in toddlers and foreign body- (FB-) induced appendicitis is rare. We present a FB-induced appendicitis in a toddler with no suggestive history of FB ingestion. Case Presentation. A 2-year-old healthy boy presented to the emergency department with irritability for 3 days duration associated with fever of 39°C, nausea, anorexia, and vomiting. There was no history of foreign body ingestion. The abdomen was distended and diffusely tender. An abdominal ultrasound (US) was suggestive of perforated appendicitis with appendicular mass formation. An abdominal X-ray showed a pin-like foreign body in the abdomen. An emergent appendectomy was performed. Intraoperatively, a sealed small cecal perforation was noticed. A 5 cm pin-like metallic foreign body was found to obstruct the appendicular lumen. The appendix was grossly normal without inflammatory changes. Conclusion. FB-induced perforations or appendicitis albeit in patients with no history of FB ingestion or infants and toddlers need a high clinical suspicion to prevent the delay in diagnosis and the subsequent complications.

Appendectomy in Patients with Morbid Obesity: Laparoscopic versus Conventional Technique

BACKGROUND Our aim was to determine the optimum appendectomy technique in patients with morbid obesity by evaluating laparoscopic appendectomy (LA) and open appendectomy (OA) operations performed in these patients. MATERIAL AND METHODS The records of 2179 patients who underwent appendectomy for acute appendicitis between January 2010 and April 2019 were evaluated retrospectively. Patients were excluded for the following: age.

Teaching surgery novices and trainees advanced laparoscopic suturing: a trial and tribulations

INTRODUCTION

The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills.

METHODS AND PROCEDURES

Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups.

RESULTS

Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups.

CONCLUSIONS

Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.

Impact of fellowship training on surgical outcomes after appendectomies: a retrospective cohort study

BACKGROUND

Outcome studies have failed to show significant improvement related to formal fellowship training in different surgical specialties. We aimed to look whether laparoscopic fellowship-trained (FT) surgeons had better outcomes.

METHODS

This is an IRB approved retrospective review from a single institution (inner city hospital) on adults undergoing appendectomy from 2008 to 2017. Demographics and 30-day complications were analyzed with univariate and multivariate logistic regression analyses.

RESULTS

Total of 558 appendectomies were reviewed. 151 (27.36%) appendectomies were performed by FT surgeons (MIS/CRS), 401 (72.64%) performed by GS. No difference in age, ASA, BMI, race, gender, insurance status, smoking, diabetes mellitus (DM), or hypertension was found. Also, similar rates of non-iatrogenic perforated appendicitis were seen (16.37% GS vs 20% FT, p = 0.318). For major complications, no difference was found between GS and FT (p = 0.63). However, appendectomies performed by GS showed higher rates of post-op ileus (3.99% vs 0.66%, p = 0.04), higher conversion to open (7.55% vs 2.67%, p = 0.039), higher rates of choosing an open approach (17.46% vs 0.66%, p =  < 0.001), and longer length of stay (LOS) (median 1.9 vs 1.8 days p = 0.048). Of the 16 patients with ileus from the GS group three were open, two converted to open, and eleven laparoscopic with mean OR time of 70 min and LOS of 13.3 days. The only laparoscopic case from the FT group with ileus had a mean operative time of 56 min and LOS of 15 days. On multivariate regression analysis, only DM was found as risk factor for major complications (OR 3.01, 95% CI 1.307-6.92, p = 0.01), while laparoscopic approach was seen as protective factor against major complications (OR 0.53, 95% CI 0.29-0.97, p = 0.04).

CONCLUSION

Laparoscopic fellowship training had a positive outcome on post-op ileus and LOS after appendectomy. This seems to be related to the higher prevalence of choosing laparoscopic technique and lower rate of conversion to open.

Pediatric appendectomy in developing countries: How does it differ from international experience?

Introduction

A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country's experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones.

Method

A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients' characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher's exact test, as for continuous, Student's t test was used or one-way ANOVA in case of more than 2 categories.

Result

Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar.

Conclusion

In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.

Obesity and appendicitis: Laparoscopy versus open technique

Objectives

The clinical results of obese patients who have undergone open or laparoscopic appendectomy, whether one technique is superior to the other is still not clearly known.In our study, we compared the clinical results of obese patients operated with laparoscopic or open technique for acute appendicitis.

Material and Methods

We performed retrospective analyses of patients operated for acute appendicitis between the dates of July 2016 and July 2019 at Istinye University Faculty of Medicine Bahcesehir Liv Training and Research Hospital and Liv Hospital Ankara. Of the 241 patients whose height and weight information was accessible, 57 had a body mass index of 30 kg/m2 or higher. Eighteen of these patients underwent open surgery while the other 39 underwent laparoscopic surgery. The primary result criterion was complication ratio. Secondary criteria were operation time and length of hospital stay.

Results

Upon comparison of laparoscopic and open techniques in terms of intraoperative-postoperative complications (p= 0.01), operation time (p= 0.02) statistically significant differences were found between the groups. However the mean length of hospital stay (p= 0.181) was similar in both groups.

Conclusion

In obese appendicitis patients, the laparoscopic technique proved to be superior to the open technique in criteria such as perioperative-postoperative complications, operation time, and etc. Length of hospital stay was determined to be similar between the groups.

Pneumoperitoneum in Veterinary Laparoscopy: A Review

Objective: To review the effects of carbon dioxide pneumoperitoneum during laparoscopy, evaluate alternative techniques to establishing a working space and compare this to current recommendations in veterinary surgery. Study Design: Literature review. Sample Population: 92 peer-reviewed articles. Methods: An electronic database search identified human and veterinary literature on the effects of pneumoperitoneum (carbon dioxide insufflation for laparoscopy) and alternatives with a focus on adaptation to the veterinary field. Results: Laparoscopy is the preferred surgical approach for many human and several veterinary procedures due to the lower morbidity associated with minimally invasive surgery, compared to laparotomy. The establishment of a pneumoperitoneum with a gas most commonly facilitates a working space. Carbon dioxide is the preferred gas for insufflation as it is inert, inexpensive, noncombustible, colorless, excreted by the lungs and highly soluble in water. Detrimental side effects such as acidosis, hypercapnia, reduction in cardiac output, decreased pulmonary compliance, hypothermia and post-operative pain have been associated with a pneumoperitoneum established with CO2 insufflation. As such alternatives have been suggested such as helium, nitrous oxide, warmed and humidified carbon dioxide and gasless laparoscopy. None of these alternatives have found a consistent benefit over standard carbon dioxide insufflation. Conclusions: The physiologic alterations seen with CO2 insufflation at the current recommended intra-abdominal pressures are mild and of transient duration. Clinical Significance: The current recommendations in veterinary laparoscopy for a pneumoperitoneum using carbon dioxide appear to be safe and effective.

Risk factors for intra-abdominal abscess following laparoscopic appendectomy for acute appendicitis: a retrospective cohort study on 2076 patients

BACKGROUND

Intra-abdominal abscesses (IAA) may develop after laparoscopic appendectomies (LA) for acute appendicitis. The identification of risk factors for postoperative IAA could lead to a decrease in the readmission rate and surgery redoes after LA for acute appendicitis.

MATERIALS AND METHODS

The present study retrospectively analyzed patients undergone LA for acute appendicitis during the period 2001-2017. Clinical, intraoperative, and postoperative outcomes were described. Comparison between groups was made via univariate and multivariate analyses.

RESULTS

The charts of 2076 patients undergone LA were reviewed. Thirty-seven patients (1.8%) developed a postoperative IAA. Male gender (p < 0.05), ASA score ≥ 2 (p < 0.05), a gangrenous or perforated appendicitis (p < 0.0001), abscess or pelvic peritonitis (p < 0.0001), clipping the mesoappendix (p < 0.0001), appendix division by mechanical stapler (p < 0.05), prolonged antibiotic therapy (p < 0.05), and piperacillin/tazocin regimen (p < 0.0001) were significantly more frequent in the group of patients with IAA. In terms of multivariate analysis, only pelvic peritonitis (p = 0.010), perforated appendicitis (p = 0.0002), and clipping the mesoappendix (p = 0.0002) were independent predictive factors for postoperative IAA.

CONCLUSION

Patients with peritonitis or a perforated appendicitis, and those who had their mesoappendix clipped showed a higher likelihood of developing an IAA. At risk patients should be provided with careful follow-up for the early detection and management of this complication.

Comparison of laparoscopic and open appendectomy on wound infection and healing in complicated appendicitis

The aim of this study was to investigate the effects of laparoscopic and open surgery on the development of postoperative surgical wound infection and wound healing between complicated appendicitis patients. Patients with complicated appendicitis were divided into those underwent laparoscopic and open surgical procedures according to the surgical method. Patients were followed up with regard to development of any postoperative wound infection, and medical, radiological, and surgical treatment methods and results were recorded. A total of 363 patients who underwent appendectomy were examined, of which 103 (28.4%) had complicated appendicitis. Postoperative wound infection rate in patients who underwent open surgery was 15.9%, while it was 6.8% in the laparoscopic surgery group. There was no statistically significant difference between the two groups in terms of infection development rates (P > .05). The rate of surgical drainage use and rehospitalisation was significantly higher in the group with wound infection than in the group without wound infection. (P < .05). We suggest that in terms of wound infection and wound healing, laparoscopic surgery should be the method of choice for patients with complicated appendicitis. In order to reduce the frequency of wound infection, drains should not be kept for a long time in patients undergoing appendectomy.

Laparoscopic versus open approach for diffuse peritonitis from appendicitis ethiology: a subgroup analysis from the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study

Diffuse peritonitis represents a life-threatening complication of acute appendicitis (AA). Whether laparoscopy is a safe procedure and presents similar results compared with laparotomy in case of complicated AA is still a matter of debate. The objective of this study is to compare laparoscopic (LA) and open appendectomy (OA) for the management of diffuse peritonitis caused by AA. This is a prospective multicenter cohort study, including 223 patients with diffuse peritonitis from perforated AA, enrolled in the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study from February to May 2018. Two groups were created: LA = 78 patients, mean age 42.51 ± 22.14 years and OA = 145 patients, mean age 38.44 ± 20.95 years. LA was employed in 34.98% of cases. There was no statically significant difference between LA and OA groups in terms of intra-abdominal abscess, postoperative peritonitis, rate of reoperation, and mortality. The wound infection rate was higher in the OA group (OR 21.63; 95% CI 3.46-895.47; P = 0.00). The mean postoperative hospital stay in the LA group was shorter than in the OA group (6.40 ± 4.29 days versus 7.8 ± 5.30 days; P = 0.032). Although LA was only used in one-third of cases, it is a safe procedure and should be considered in the management of patients with diffuse peritonitis caused by AA, respecting its indications.

Global incidence of surgical site infection after appendectomy: a systematic review and meta-analysis

BACKGROUND

Although surgical site infection (SSI) is one of the most studied healthcare-associated infections, the global burden of SSI after appendectomy remains unknown.

OBJECTIVE

We estimated the incidence of SSI after appendectomy at global and regional levels.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Appendectomy patients.

DATA SOURCES

EMBASE, PubMed and Web of Science were searched, with no language restrictions, to identify observational studies and clinical trials published between 1 January 2000 and 30 December 2018 and reporting on the incidence of SSI after appendectomy. A random-effect model meta-analysis served to obtain the pooled incidence of SSI after appendectomy.

RESULTS

In total, 226 studies (729 434 participants from 49 countries) were included in the meta-analysis. With regard to methodological quality, 59 (26.1%) studies had low risk of bias, 147 (65.0%) had moderate risk of bias and 20 (8.8%) had high risk of bias. We found an overall incidence of SSI of 7.0 per 100 appendectomies (95% prediction interval: 1.0-17.6), varying from 0 to 37.4 per 100 appendectomies. A subgroup analysis to identify sources of heterogeneity showed that the incidence varied from 5.8 in Europe to 12.6 per 100 appendectomies in Africa (p<0.0001). The incidence of SSI after appendectomy increased when the level of income decreased, from 6.2 in high-income countries to 11.1 per 100 appendectomies in low-income countries (p=0.015). Open appendectomy (11.0 per 100 surgical procedures) was found to have a higher incidence of SSI compared with laparoscopy (4.6 per 100 appendectomies) (p=0.0002).

CONCLUSION

This study suggests a high burden of SSI after appendectomy in some regions (especially Africa) and in low-income countries. Strategies are needed to implement and disseminate the WHO guidelines to decrease the burden of SSI after appendectomy in these regions.

PROSPERO REGISTRATION NUMBER

CRD42017075257.

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Laparoscopic colposuspension was one of the first minimal access operations for treating stress urinary incontinence in women, with the presumed advantages of shorter hospital stays and quicker return to normal activities. This Cochrane Review was last updated in 2010.

OBJECTIVES

To assess the effects of laparoscopic colposuspension for urinary incontinence in women; and summarise the principal findings of relevant economic evaluations of these interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (22 May 2019), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials of women with urinary incontinence that included laparoscopic surgery in at least one arm.

DATA COLLECTION AND ANALYSIS

We independently extracted data from eligible trials, assessed risk of bias and implemented GRADE.

MAIN RESULTS

We included 26 trials involving 2271 women. Thirteen trials (1304 women) compared laparoscopic colposuspension to open colposuspension and nine trials (412 women) to midurethral sling procedures. One trial (161 women) compared laparoscopic colposuspension with one suture to laparoscopic colposuspension with two sutures; and three trials (261 women) compared laparoscopic colposuspension with sutures to laparoscopic colposuspension with mesh and staples. The majority of trials did not follow up participants beyond 18 months. Overall, there was unclear risk of selection, performance and detection bias and generally low risk of attrition and reporting bias. There is little difference between laparoscopic colposuspension using sutures and open colposuspension for subjective cure within 18 months (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.99 to 1.08; 6 trials, 755 women; high-quality evidence). We are uncertain whether laparoscopic colposuspension using mesh and staples is better or worse than open colposuspension for subjective cure within 18 months (RR 0.75, 95% CI 0.61 to 0.93; 3 trials, 362 women; very low-quality evidence) or whether there is a greater risk of repeat continence surgery with laparoscopic colposuspension. Laparoscopic colposuspension may have a lower risk of perioperative complications (RR 0.67, 95% CI 0.47 to 0.94; 11 trials, 1369 women; low-quality evidence). There may be similar or higher rates of bladder perforations with laparoscopic colposuspension (RR 1.72, 95% CI 0.90 to 3.29; 10 trials, 1311 women; moderate-quality evidence). Rates for de novo detrusor overactivity (RR 1.29, 95% CI 0.72 to 2.30; 5 trials, 472 women) and voiding dysfunction (RR 0.81, 95% CI 0.50 to 1.31; 5 trials, 507 women) may be similar but we are uncertain due to the wide confidence interval. Five studies reported on quality of life but we could not synthesise the data. There may be little difference between laparoscopic colposuspension using sutures and tension-free vaginal tape (TVT) for subjective cure within 18 months (RR 1.01, 95% CI 0.88 to 1.16; 4 trials, 256 women; low-quality evidence) or between laparoscopic colposuspension using mesh and staples and TVT (RR 0.71, 95% CI 0.55 to 0.91; 1 trial, 121 women; low-quality evidence). For laparoscopic colposuspension compared with midurethral slings, there may be lower rates of repeat continence surgery (RR 0.40, 95% CI 0.04 to 3.62; 1 trial, 70 women; low-quality evidence) and similar risk of perioperative complications (RR 0.99, 95% CI 0.60 to 1.64; 7 trials, 514 women; low-quality evidence) but we are uncertain due to the wide confidence intervals. There may be little difference in terms of de novo detrusor overactivity (RR 0.80, 95% CI 0.34 to 1.88; 4 trials, 326 women; low-quality evidence); and probably little difference in terms of voiding dysfunction (RR 1.06, 95% CI 0.47 to 2.41; 5 trials, 412 women; moderate-quality evidence) although we are uncertain due to the wide confidence interval. Five studies reported on quality of life but we could not synthesise the data. No studies reported on bladder perforations. Low-quality evidence indicates that there may be higher subjective cure rates within 18 months with two sutures compared to one suture (RR 1.37, 95% CI 1.14 to 1.64; 1 trial, 158 women). Comparing one suture and two sutures, one suture may have lower rates of repeat continence surgery (RR 0.35, 95% CI 0.01 to 8.37; 1 trial, 157 women) and similar risk of perioperative complications (RR 0.88, 95% CI 0.45 to 1.70) but we are uncertain due to the wide 95% CIs. There may be higher rates of voiding dysfunction with one suture compared to two sutures (RR 2.82; 95% CI 0.30 to 26.54; 1 trial, 158 women; low-quality evidence), but we are uncertain due to the wide confidence interval. This trial did not report bladder perforations, de novo detrusor overactivity or quality of life. We are uncertain whether laparoscopic colposuspension with sutures is better or worse for subjective cure within 18 months compared to mesh and staples (RR 1.24, 95% CI 0.96 to 1.59; 2 trials, 180 women; very low-quality evidence) or in terms of repeat continence surgery (RR 0.97, 95% CI 0.06 to 14.91; 1 trial, 69 women; very low-quality evidence). Laparoscopic colposuspension with sutures may increase the number of perioperative complications compared to mesh and staples (RR 1.94, 95% CI 1.09 to 3.48; 3 trials, 260 women; low-quality evidence) but rates of de novo detrusor overactivity may be similar (RR 0.72, 95% CI 0.17 to 3.06; 2 trials, 122 women; low-quality evidence), however, we are uncertain due to the wide confidence interval. None of the studies reported bladder perforations, voiding dysfunction or quality of life.

AUTHORS' CONCLUSIONS

The data indicate that, in terms of subjective cure of incontinence within 18 months, there is probably little difference between laparoscopic colposuspension and open colposuspension, or between laparoscopic colposuspension and midurethral sling procedures. Much of the evidence is low quality, meaning that a considerable degree of uncertainty remains about laparoscopic colposuspension. Future trials should recruit adequate numbers, conduct long-term follow-up and measure clinically important outcomes. A brief economic commentary identified three studies. We have not quality-assessed them and they should be interpreted in light of the findings on clinical effectiveness.

Medical Treatment: An Emerging Standard in Acute Appendicitis?

Appendicectomy has been accepted as the gold standard for the management of appendicitis over the years, but there has been an increasing evidence and trend toward the conservative approach to the management of appendicitis. The aim of this review is to search existing literature and to evaluate and compare the conservative and operative approaches to the management of appendicitis. An electronic search of published literature was conducted through Pubmed, Google Scholar, Embase, and Medline using a variety of search items to find relevant observational studies, randomized clinical trials, systematic reviews, and meta-analyses. Bibliographies of selected articles were also analyzed for publications of interest relevant to the scope of the topic. The articles that reported primary outcomes after the management of appendicitis, complications, economic implications, and duration of follow-up were reviewed in detail. The major primary outcomes show a high recurrence rate and failed treatment associated with the conservative management of appendicitis. The other outcomes obtained show that there is an increased incidence of complications associated with operative management. Economic implications and cost-effectiveness analysis show that conservative treatment may be preferred. The length of hospital stay was significantly higher in conservative approach to management; however, shorter time off activities was observed. In general, the conservative management of appendicitis is still regarded as safe, effective, and efficacious, and further research with well-constructed study design, and larger sample size is required.

A comparison of non-absorbable polymeric clips and staplers for laparoscopic appendiceal stump closure: analysis of 618 adult patients

PURPOSE

The aim of this long-term study was the comparison of appendiceal stump closure with polymeric clips or staplers with respect to perioperative costs and surgical outcome under routine conditions in a university centre.

METHODS

For this retrospective chart review, a total of 618 patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2010 and 2017 were reviewed: 410 patients in the stapler group and 208 patients in the clip group. The database contained demographic data, operation time, inflammation parameters, closure method of the stump, surgeon status, length of hospital stay, and complications as well as histology reports. The costs were also compared.

RESULTS

Clip application was more likely among younger patients (mean age 33.6 years vs. 41.7 years). Histopathological evidence for appendiceal pathology was found in 96.6% of patients in the clip group and 99.5% of patients in the stapler group. Laparoscopic appendectomy in the clip group was more frequently performed by resident physicians (69.2%) than in the stapler group (57.8%). The mean postoperative stay was 2.9 days in the clip group and 3.7 days in the stapler group. The use of the polymeric clip resulted in considerable cost savings (19.94€ vs. 348.70€).

CONCLUSIONS

The use of polymeric clips for appendiceal stump closure during appendectomy is safe and effective. The base of the appendix is amenable to clipping in 32% of appendectomies in adult patients. This study supports the use of polymeric clips over staplers to decrease cost and environmental impact.

Exploring geographic variation in acute appendectomy in Ireland: results from a national registry study

OBJECTIVE

To explore geographic variations in Irish laparoscopic and open appendectomy procedures.

DESIGN

Analysis based on 2014-2017 administrative hospital data from public hospitals.

SETTING

Counties of Ireland.

PARTICIPANTS

Irish residents with hospital admissions for an appendectomy as the principal procedure.

MAIN OUTCOME MEASURES

Age and gender standardised laparoscopic and open appendectomy rates for 26 counties. Geographic variation measured with the extremal quotient (EQ), coefficient of variation (CV) and the systematic component of variation (SCV).

RESULTS

23 684 appendectomies were included. 77.6% (n= 18,387) were performed laparoscopically. An EQ of 8.3 for laparoscopy and 10.0 for open appendectomy was determined. A high CV was demonstrated with a value of 36.7 and 80.8 for laparoscopic and open appendectomy, respectively. An SCV of 14.2 and 124.8 for laparoscopic and open appendectomy was observed. A wider variation was determined when children and adults were assessed separately.

CONCLUSIONS

The geographic distribution in rates of appendectomy varies considerably across Irish counties. Our data suggest that a patient's likelihood of undergoing a laparoscopic or open appendectomy is associated with their county of residence.

Apendicectomía por único puerto asistida por laparoscopia versus técnica abierta convencional localizada, en pacientes con apendicitis aguda en el Hospital Universitario Clínica San Rafael

Introducción. La apendicectomía por puerto único, asistida por laparoscopia, ofrece una alternativa terapéutica en el abordaje de la apendicitis aguda. En el presente estudio, se evalúa el beneficio terapéutico de la técnica por único puerto asistida por laparoscopia y se compara esta técnica con la apendicectomía abierta. Materiales y métodos. Se trata de un estudio observacional analítico retrospectivo de cohorte, llevado a cabo en el Hospital Universitario Clínica San Rafael, de Bogotá. Se incluyeron 106 pacientes mayores de 15 años con apendicitis aguda, que fueron sometidos a apendicectomía por puerto único, asistida por laparoscopia o apendicectomía abierta. La relación entre el grupo con apendicectomía por laparoscopia y el de técnica abierta, fue de 1:1. Se incluyeron variables sociodemográficas, clínicas y quirúrgicas (tiempo quirúrgico, frecuencia de infección del sitio operatorio, estancia hospitalaria, dolor, reingresos y resultado estético). Resultados. La edad promedio fue de 32 años y la mayoría de los pacientes eran de sexo masculino. El tiempo operatorio fue menor en los casos de apendicectomía por puerto único, asistida por laparoscopia, con un promedio de 34,1 minutos. Según la escala análoga, el dolor posoperatorio fue de 2,2 con la técnica laparoscópica y de 3,2 con la apendicectomía abierta (p<0,05). Hubo ocho veces más reingresos entre los casos de apendicectomía abierta en comparación con la apendicectomía por un puerto, y el resultado estético fue satisfactorio en todos con esta última técnica. No se encontraron diferencias significativas en la estancia hospitalaria o la infección del sitio operatorio. La razón de momios (odds ratio, OR) fue inferior a 1 en variables como dolor, reingreso y menor tiempo quirúrgico, lo cual indica una menor probabilidad, en los que se usó un solo puerto. Discusión. La técnica por un solo puerto es segura, reproducible, equiparable en términos de días de estancia hospitalaria e infección de sitio operatorio, e incluso, produce mejores resultados en el tiempo quirúrgico, las escalas de dolor y el número de reingresos.

Cost analysis of antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: 5-year results of the APPAC randomized clinical trial

BACKGROUND

The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years.

METHODS AND FINDINGS

This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy.

CONCLUSIONS

At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.

Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy

BACKGROUND

Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA.

METHODS

A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017.

RESULTS

During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1 days vs. 10.1 and 9.0 days, p = <0.003). The mean time for resolution of SIRS was significantly shorter (2.0 days vs. 3.3 and 5.2 days, p <0.02). The morbidity and length of stay were similar.

CONCLUSION

Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.

Appendiceal stump closure with polymeric clips is a reliable alternative to endostaplers

Objective

Polymeric (Hem-o-lok) clips represent a novel technique with which to ligate the appendiceal stump following laparoscopic appendectomy. We compared the outcomes of using polymeric clips versus endostaplers for complicated and uncomplicated appendicitis.

Methods

Six hundred seventy-three consecutive patients undergoing laparoscopic appendectomy with polymeric clips or endostaplers for acute appendicitis were assessed. The primary outcome was the incidence of intra-abdominal abscesses. Predictors of postoperative intra-abdominal abscesses were calculated using univariate and multivariate analyses.

Results

Polymeric clips were used in 65% of patients and endostaplers were used in 35%. Hem-o-lok clips were not only applied in patients with uncomplicated appendicitis (83%), but also in those with complicated appendicitis (26%). The frequency of intra-abdominal abscesses using polymeric clips and endostaplers was similar in both patients with uncomplicated appendicitis (1% vs. 3%, respectively) and complicated appendicitis (2% vs. 6%, respectively). The univariate and multivariate analyses showed that the stump closure technique was not a risk factor for postoperative abscesses.

Conclusions

Closure of the appendiceal stump using the nonabsorbable Hem-o-lok ligation system in patients with both uncomplicated and complicated appendicitis is a safe alternative to the application of endostaplers.